Failure to Analyze and Document QAPI Data and Actions
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified problem areas. Review of QAPI meeting minutes from April 2024 through March 2025 revealed that while issues such as falls, family notification for therapy, completion of forms, resident toileting, and repositioning were identified, there were no documented goals, action plans, methods for data collection, or analysis of the information. Several meetings did not include any review of ongoing projects or associated data, and even when quality indicators were discussed, there was no follow-through with measurable goals or action plans. An interview with facility leadership, including the QAPI director, administrator, and DON, confirmed that a thorough analysis of data, including the establishment of measurable goals, plans, or outcomes, had not been completed. The facility's QAPI policy required tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing causes, developing corrective action plans, and monitoring outcomes, but these components were not implemented as required. This deficiency had the potential to affect all 47 residents in the facility.